Quality of Life and Therapeutic Objectives

Geriatric Essentials

• Health-related quality of life is best evaluated based on the patient's experiences, relationships with family members and friends, and cultural background. Clinicians should not make assumptions about a patient's quality of life based on the patient's age, primary diagnosis, or their own biases.
• Therapeutic objectives should be based on the patient's wishes, comorbidities, estimated survival, and the likelihood that an intervention will improve quality of life or life expectancy, rather than on the patient's age. The patient's dignity and autonomy must always be considered.

A patient's age should not affect the approach to clinical care (eg, relief of suffering, cure when possible) or therapeutic objectives (eg, optimal health-related quality of life, independence, other outcomes consistent with the patient's personal beliefs and objectives).

Quality of life: Quality of life is an intensely personal and variable concept. Many elderly people report a high quality of life despite changes in their circumstances and their losses.

Most people are comfortable talking about their own quality of life but become uncertain and reluctant if asked to estimate the quality of life in others. Thus, clinicians can best evaluate health-related quality of life based on a patient's experiences, quality of relationships with family members and friends (which greatly influence the patient's decisions about therapeutic goals), and cultural background. Frequent, frank discussions with the patient about lifetime goals and aspirations help clinicians act on the patient's behalf; these discussions should focus on the patient's preferences (eg, based on religious beliefs, personal values, or previous experiences with health care) and perception of health-related quality of life. Clinicians should take great care not to reveal their own quality-of-life biases during discussions with a patient. Research questionnaires and other instruments that measure health-related quality of life are rarely clinically useful.

Therapeutic objectives: Therapeutic objectives are best guided by the presence and severity of mental or physical suffering or pain and by the likelihood that treatment will restore lifestyle and pleasures or result in suffering. Before a treatment is begun, the potential adverse effects of a proposed diagnostic test or treatment (eg, medical complications, discomfort, inconvenience, the perceived need to follow up with additional diagnostic tests or treatments) should be weighed against the potential benefit. Comorbidities may influence the benefit-to-risk ratio, but determination of the need to modify treatment should not be based only on a patient's age or primary diagnosis. The results of this analysis, including adverse effects and other consequences of a treatment, must be shared with patients. Only then can patients make an informed decision consistent with their personal values and goals.

Some ethicists have proposed that age be a criterion for rationing or withholding specific treatment and that ill patients > 75 should be offered palliation only. By ignoring differences in individual characteristics (especially functional status) and health care preferences among elderly patients, such proposals are likely to do more harm than good to patients and to society.

Several factors that become more prevalent with aging must be considered when health care is planned. They include chronic disorders (which may be accompanied by physical disability), pain and suffering, cognitive impairment, institutionalization (eg, in a nursing home), reduced life expectancy, heavy use of health care resources, accumulation of losses (eg, of a spouse or partner, economic status, physical health, or overall independence), dependence on family members and friends, and social isolation.

Chronic Disorders

In the US, > 80% of community-dwelling people > 65 have at least one chronic disorder. About 50% have some limitations in performing activities of daily living; about 5 to 8% need assistance with >= 1 activities of daily living. About 5% of people > 65, about 15% of those > 75, and about 25% of those > 80 are homebound. Chronic disorders cause 80% of deaths after age 65 and account for > 80% of health care expenditures in the US.

Therefore, the health care delivery system for elderly people should be oriented toward management of chronic disorders, regardless of the patient's age, and should emphasize continuing care aimed at improving or maintaining function and quality of life, postponing deterioration and disability, and preventing complications.

Pain and Suffering

Pain affects function; effects range from a trivial, virtually unnoticed decline to agonizing incapacity and immobilization. Objective pain scales reliably measure the absolute and relative intensity of pain over time. Evaluation of the severity of pain as perceived by the patient and of its effects on comfort, activities, and quality of life enables a clinician to determine when the focus of treatment must be relief of pain and suffering. Concerns about addiction and other complications (eg, falls, increased somnolence, confusion, delirium) can result in significant undertreatment of pain in frail or institutionalized patients. Some concerns are legitimate; for example, sometimes complete relief of pain is impossible without causing somnolence or confusion. However, complications must be balanced against the imperative to relieve pain and suffering. Patients or their health care proxy should be informed of the risks and benefits of treatment. A combination of appropriate analgesic drugs in modified doses and nondrug measures can often provide relief with a minimum of adverse effects.

Cognitive Impairment

Evaluation of the severity and functional effect of cognitive impairment helps a clinician better communicate with patients. As a result, patients are more likely to understand and to consent to appropriate treatment. Explaining risks and benefits to cognitively impaired patients, although complicated and time-consuming, is essential to high-quality care; generally, close family members should be present in such cases. If asked simple questions, many patients with mild cognitive impairment or mild dementia can adequately and consistently communicate their wishes. If patients have more advanced dementia, their health care proxy or loved ones may be able to provide this information. If possible, patients should document their wishes or, at least, their health care proxy in an advance directive before they become cognitively impaired.

Institutionalization

Among nursing home residents, the prevalence of factors that can affect therapeutic objectives is disproportionately high. Chronic disorders, physical disability, pain and suffering, cognitive impairment, reduced life expectancy, accumulated losses, poverty, and social isolation are common. Nonetheless, how residents view their health-related quality of life must be considered. Regardless of residents' age or the type of institution, clinicians must discuss treatment issues with residents and their family members or proxy. Using terms residents can understand and respecting their cultural values or preferences and their autonomy (which they or their family members may view as greatly limited by institutionalization) are crucial.

Reduced Life Expectancy

Life expectancy based on predictions related to a cohort (eg, nearly 20 yr for a 65-yr-old woman, 16 yr for a 65-yr-old man) cannot be the sole criterion for treatment decisions. For example, an 85-yr-old man has an average life expectancy of only 5.7 yr; should coronary artery bypass or knee replacement surgery with a high probability of improving function therefore be withheld from such a patient? Risk of functional decline and likelihood of survival must be estimated based on individual clinical and demographic characteristics; this approach enables clinicians to predict outcome more accurately and to make better decisions about the merit of a treatment.

When the prognosis is poor (eg, reduced life expectancy), treatment must be planned accordingly, regardless of the patient's age. After patients are told the potential adverse effects and other consequences of treatment, they may choose to forgo treatment if they perceive any extension of life as prolongation of suffering. If patients have a reduced life expectancy and are suffering severely, they should be offered hospice care.

Palliation should be offered regardless of disease severity or life expectancy. Patients may not be aware of this option or may misunderstand their prognosis.

For elderly patients who cherish any additional few days, weeks, or months, preserving life through medical intervention (heroic or ordinary) may be more important than maintaining optimum quality of life.

This topic was last updated July 2006.